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*  "1  he     Significance    and 


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RC73  .  F49  1914      The  significance  and 


Effect     of     Pain 


Ether  Day  Address 
1914 


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The     Significance     and 
::       Effect     of     Pain       :: 


BY 
JOHN  M.  T.  FINNEY,  M.  D. 

Professor  of  Clinical  Surgery 
Johns  Hopkins  Hospital 


Ether  Day  Address 
1914 


Griffith-Stillings  Press 
Boston,  Mass. 


THE   SIGNIFICANCE  AND   EFFECT 
OF  PAIN* 

By  John  M.  T.  Finney,  M.D.,  Baltimore 
Professor  of  Clinical  Surgery,  Johns  Hopkins  Hospital 

For  the  great  honor  of  being  invited  to  deliver  the  Ether 
Day  Address  for  the  year  1914,  I  wish  first  to  express  my 
sincere  thanks  and  appreciation  to  the  trustees  and  officers 
of  the  Massachusetts  General  Hospital.  Returning,  as  I  do, 
after  the  lapse  of  a  quarter  of  a  century,  my  mind  is  filled 
with  memories  of  the  time  so  pleasantly  and  profitably  spent 
as  a  house  pupil  in  the  wards  of  this  hospital,  just  twenty- 
five  years  ago.  As  a  member  of  the  old  West  Side  surgical 
staff,  it  was  my  great  privilege  to  serve  under  those  master 
surgeons,  John  Homans,  Charles  B.  Porter,  and  Arthur  T. 
Cabot,  and  to  have  the  opportunity  to  observe  the  work  of 
their  equally  illustrious  colleagues  on  the  East  Side,  H.  H.  A. 
Beach,  Maurice  H.  Richardson,  and  John  Collins  Warren. 
I  should  be  untrue  to  myself  and  ungrateful  indeed  if  I 
failed  at  this  time  and  in  this  place  to  acknowledge  the 
debt  that  I  owe  to  these  distinguished  men  and  their  associ- 
ates upon  the  staff  of  this  hospital,  for  the  stimulus  received 
from  them  toward  high  ideals  in  thought  and  work;  for 
kindly  admonition  and  advice;  for  encouragement  when 
sorely  needed;  and  best  of  all,  for  that  unconscious  aid  and 
instruction  so  freely  imparted  and  received  in  that  intimate 
personal  association  which  always  characterizes  the  relation- 
ship between  the  true  teacher  and  his  pupils.  The  Massa- 
chusetts General  Hospital,  in  the  value  of  its  scientific 
achievements  and  in  its  long  roll  of  illustrious  names,  has 
contributed  much  to  American  medicine.  From  its  earliest 
beginnings  it  has  always  stood  for  the  best  things  in  medicine 
and  surgery,  and  in  many  respects  has  served  as  a  model  for 
others  to  follow.  But  illustrious  as  is  its  past  and  glorious 
as  are  the  promises  for  its  future,  for  me  at  least  it  can  never 
be  quite  the  same  as  it  was  twenty-five  years  ago.  For  I 
miss  the  presence  of  those,  my  teachers  and  friends,  who  by 


*  Address  delivered  at  the  Massachusetts  General  Hospital ,  on  Sixty-eighth  Anni- 
versary of  Ether  Day,  October  16,  1914. 


their  strong  personalities  made  this  hospital  what  it  was  to 
us  who  were  fortunate  enough  to  have  been  in  any  way 
associated  with  them.  Recurring  visits  to  these  venerable 
halls  from  time  to  time  have  been  saddened  by  the  loss,  one 
after  another,  of  these  familiar  faces,  until  now  but  one 
remains,  full  of  years  and  of  honors  richly  deserved  and 
honestly  won.  Long  may  he  live,  and  never  grow  older,  to 
enjoy  the  fruits  of  his  abundant  labors  and  the  affectionate 
regard  of  his  friends  and  former  pupils. 

Upon  this  occasion  when  we  are  gathered  together  to 
celebrate  what  Dr.  Mitchell  has  so  happily  termed  the 
"Death  of  Pain,"  it  is  fitting  that  we  should  stop  for  a 
moment  to  consider  as  best  we  can  just  what  it  would  mean 
if  this  designation  were  literally  true.  Would  that  it  were! 
But  as  a  matter  of  fact  the  field  of  usefulness  of  ether,  large 
and  important  as  it  is,  does  not  extend  far  beyond  the 
confines  of  the  operating  room.  Here  it  has  through  its 
beneficent  influence  largely  robbed  surgical  operations  of 
their  terrors  both  for  the  patient  and  the  surgeon,  for  in 
these  days  the  performance  of  a  major  surgical  operation 
upon  a  conscious,  suffering  patient  is  almost  inconceivable. 
They  were  indeed  giants  in  the  surgical  profession  in  those 
pre-anesthetic  days,  men  of  iron  nerve  and  indomitable  will, 
who  could  bring  themselves  to  inflict  such  untold  anguish 
upon  their  fellow-men,  even  in  the  hope  of  ultimate  relief. 
And  what  of  the  patient?  This  is  but  a  marked  illustration 
of  the  impelling  power  of  pain,  for  it  requires  but  a  bad 
enough  pain  for  a  long  enough  time  to  break  down  all  bar- 
riers and  to  cause  the  sufferer  to  submit  willingly,  yes, 
eagerly,  to  anything  at  all,  even  death  itself,  that  offers  hope 
of  relief. 

We  have  tried  with  but  ill  success  to  picture  in  our  mind 
a  world  that  was  literally  free  from  pain.  What  a  Paradise 
it  would  be!  Suppose  that  such  a  thing  as  the  abolition  of 
pain  were  possible.  This  of  necessity  would  almost  mean 
the  abolition  of  disease,  for  it  is  quite  impossible  to  think  of 
pain  apart  from  disease  or  injury,  the  two  have  been  for  so 
long  a  time  so  intimately  associated  in  the  human  mind.  For 
what  is  the  meaning  of  the  term  disease,  dis-ease,  but  the 
opposite  of  comfort,  and  what  is  that  in  its  commonest  form 

4 


but  pain?  Rob  ill  health  of  the  pain  it  causes  and  its  chief 
terror  is  gone.  But  try  for  a  moment  to  form  some  sort  of 
a  mental  picture  of  the  conditions  that  would  exist  under 
such  circumstances.  Would  the  world  be  better  off  or  not? 
In  other  words,  is  the  existence  of  pain  of  any  distinct 
benefit  to  the  human  race,  or  is  it  not?  In  what  ways  is  it 
harmful,  how  beneficial?  Every  one  who  has  been  obliged 
from  any  cause  to  experience  it,  or  who  has  witnessed  its 
effect  upon  others,  can  well  appreciate  what  a  boon  to 
humanity  its  abolition  would  be.  To  be  relieved  of  the 
mental  anguish,  the  awful  fear  and  dread  of  a  recurrence  of 
an  attack  of  pain  through  which  one  may  have  passed, 
means  almost  as  much  as  to  be  relieved  of  the  pain  itself. 
Think  what  all  this  would  mean  to  suffering  humanity.  It 
cannot  be  estimated! 

On  the  other  hand,  is  there  anything  that  would  be  lost 
that  is  of  real  advantage?  This  suggests  the  thought  that, 
after  all,  pain  may  have  its  uses  and  a  definite  value  both  to 
the  patient  and  to  the  surgeon.  What  are  they?  What  are 
its  effects,  good  as  well  as  bad?  We  may  hope,  perhaps,  by 
observation  and  investigation  to  gain  some  insight  into  these 
effects  and  learn  something  of  its  clinical  significance.  It  is 
to  this  phase  of  the  subject  that  I  wish  particularly  to  direct 
your  attention. 

These  questions  must,  I  am  sure,  have  come  with  especial 
emphasis  to  every  thoughtful  surgeon,  accustomed  as  he  is 
from  the  nature  of  his  work  to  the  sight  and  sounds  of  pain; 
called  upon  as  he  is  to  inflict  pain  that  relief  may  follow,  to 
witness  daily  its  effects  and  results,  and  to  try  to  find  out 
and  remove  its  causes.  They  must  also  have  come,  and 
with  even  greater  force,  to  one  who  has  been  called  upon 
himself  to  lie  upon  a  bed  of  suffering,  and  has  counted  the 
hours  as  they  dragged  wearily  and  endlessly  through  the 
long  night  watches;  or  who,  while  keeping  sleepless  vigil 
by  the  bedside  of  some  loved  one,  has  listened  helplessly  to 
the  stifled  cries  and  groans,  or,  harder  still,  has  witnessed 
in  the  agonized  countenance  the  mute  evidences  of  intense 
pain.  He  must  many  times  have  wondered  at  it  all  and  asked 
himself  the  question,  "Why  must  it  be  so?"  Why  should 
human  beings  be  called  upon  to  suffer  as  some  of  them  are, 

5 


the  innocent  along  with  the  guilty?  Because  the  fathers 
have  eaten  sour  grapes  why  should  the  children's  teeth  be 
put  on  edge? 

Ever  since  that  evening  in  the  Garden  of  Eden  when  the 
curse  of  sorrow  and  pain  was  placed  upon  our  first  parents 
these  as  yet  unanswered  queries  have  lingered  in  the  minds 
of  their  descendants,  and  I  fancy  that  they  will  continue 
to  arise  in  the  minds  of  succeeding  generations,  and  will 
fail  of  a  satisfactory  answer  until  the  dawning  of  that  blessed 
day  to  which  reference  is  made  in  the  inscription  carved 
upon  the  monument  erected  to  commemorate  this  happy 
event,  which  stands  in  yonder  Public  Garden,  "Neither 
shall  there  be  any  more  pain." 

The  mystery  of  pain!  Has  anything  in  the  way  of  human 
experience  given  rise  to  more  wonder  or  speculation  than 
this?  The  passions,  love  and  hate,  have  at  times,  perhaps, 
stirred  to  greater  action  or  deeper  feeling.  Religious  zeal 
has  aroused  and  lifted  the  thoughts  and  emotions  to  higher 
planes,  patriotism  and  the  martial  spirit  have  ever  spurred 
to  deeds  of  heroism  and  valor,  but  I  doubt  whether  any 
other  human  experience  has  been  more  universal  or  more 
controlling  than  that  of  pain.  The  pursuit  of  pleasure  in 
some  of  its  manifold  forms  has  occupied  the  mind  more 
continuously,  perhaps,  but  the  avoidance  of  pain  and  the 
institution  of  measures  to  relieve  it  have  ever  occupied  a 
not  inconsiderable  share  of  its  attention,  and  will  continue 
to  do  so  until  the  end  of  time. 

Most  of  the  important  epochs  of  a  lifetime  are  intimately 
associated  with  pain  or  are  greatly  influenced  by  it.  The 
beginning  of  life  and  the  end  of  it  are  occasions  that  are 
rarely  dissociated  from  pain.  We  speak  of  the  pains  of 
labor  in  such  a  way  that  the  two  terms  are  almost  synony- 
mous, and  one  rarely  thinks  of  the  one  without  the  sug- 
gestion of  the  other.  This  is  likewise  true  of  the  other 
extreme  of  life,  but  not  to  the  same  extent.  The  "pangs 
of  death"  is  an  expression  used  by  the  poets,  but  neverthe- 
less an  intimate  association  of  ideas  is  thereby  expressed 
which,  while  more  fanciful  than  real,  perhaps,  has  its  effect 
upon  the  human  mind.  Few  experiences,  indeed,  there  are 
that  are  really  worth  while  that  are  not  in  some  way  or  other 

6 


intimately  associated  with  or  influenced  by  human  suffering. 
Pain  is  such  a  universal  experience  that  it  has  been  felt  in  a 
greater  or  less  degree  by  every  one.  Indeed  psychologists 
tell  us  that  we  never  have  a  sensation  or  an  idea  which  is 
not  felt  with  some  degree  of  pleasure  or  pain,  and  so  it  is 
that  the  study  of  it  has  excited  interest  in  many  minds  and 
in  all  ages.  But  its  cause  and  the  reason  why  remain  a 
mystery  still. 

What  will  implacable,  beyond  our  ken, 

Set  this  stern  fiat  for  the  tribes  of  men! 

This  none  shall  'scape  who  share  our  human  fates : 

One  stern  democracy  of  anguish  waits 

By  poor  men's  cots,  —  within  the  rich  man's  gates. 

What  purpose  hath  it?    Nay,  thy  quest  is  vain: 

Earth  hath  no  answer:  if  the  baffled  brain 

Cries,  'tis  to  warn,  to  punish  —  Ah,  refrain! 

When  writhes  the  child  beneath  the  surgeon's  hand, 

What  soul  shall  hope  that  pain  to  understand? 

Lo!    Science  falters  o'er  the  hopeless  task, 

And  Love  and  Faith  in  vain  an  answer  ask, 

When  thrilling  nerves  demand  what  good  is  wrought, 

Where  torture  clogs  the  very  source  of  thought. 

— Weir  Mitchell. 

It  is  a  difficult  task  that  we  have  set  ourselves,  the  dis- 
cussion of  the  significance  and  effect  of  pain.  The  subject 
is  a  very  broad  one,  too  broad,  indeed,  to  do  full  justice  to  in 
the  limited  time  at  our  disposal.  It  is  many  sided,  and  we 
can  do  no  more  than  indicate  and  briefly  discuss  some  of 
the  phases  that  are  of  particular  interest  and  real  significance 
to  the  surgeon. 

The  cause  of  pain  is  one  thing,  its  significance  another. 
But  in  order  the  more  fully  to  understand  the  one  we  must 
know  something  about  the  other.  Indeed,  it  is  absolutely 
essential  to'  be  more  or  less  familiar  with  the  results  of 
recent  investigations  in  order  to  be  able  to  understand  many 
of  the  phenomena  observed.  As  is  usually  the  case  in  every 
live  subject,  the  observations  and  opinions  of  investigators 
in  this  field  do  not  entirely  agree.  Nevertheless,  certain 
fundamental  facts  have  been  established,  a  brief  summary 
of  which  will  aid  us  to  a  better  understanding  of  our  subject. 

In  the  preparation  of  this  paper  we  have  consulted  many 

7 


authors,  —  Hilton,  Lennander,  Mackenzie,  Ross,  Head, 
Sherrington,  Meltzer,  Hertz,  Schmidt,  Howell,  Behan,  Crile, 
Cannon,  and  others,  and  we  wish  here  to  make  acknowl- 
edgment of  the  free  use  made  of  their  opinions  and  results. 

The  anatomy  and  physiology  of  the  pain-conducting 
apparatus  has  been  carefully  studied  by  many  observers, 
but  as  yet  no  very  satisfactory  results  have  been  obtained. 
They  tell  us  that  "Pain  is  probably  the  sense  that  is  most 
widely  distributed  in  the  body.  It  is  present  throughout 
the  skin,  and  under  certain  conditions  may  be  aroused  by 
stimulation  of  sensory  nerves  in  the  various  visceral  organs, 
indeed  in  all  the  membranes  of  the  body." 

Experimental  studies  upon  the  exposed  brains  of  living 
animals,  as  well  as  clinical  observations  upon  conscious 
patients  in  the  course  of  surgical  operations,  giving  rise  to 
extensive  explorations  into  the  tissues  of  the  brain  itself, 
lead  to  the  belief  that  it  is  insensible  to  pain.  Cushing  was 
the  first  to  show  that  the  dura  also  was  insensible  to  the 
ordinary  stimuli  for  pain.  The  adequate  stimulus  here  seems 
to  be,  as  in  the  intestine,  tension  in  some  form. 

"For  cutaneous  pain,  at  least,  the  evidence  is  very  strongly 
in  favor  of  the  view  that  there  exists  a  special  set  of  fibers 
which  have  a  specific  energy  for  pain.  It  would  appear  that 
the  pain  sense  has  a  punctiform  distribution  in  the  skin. 
Histological  examination  of  these  pain  points  indicates  that 
they  have  no  special  end  organ,  the  stimulus  taking  effect 
upon  the  free  end  of  the  nerve  fibers"  (Howell).  Any  of 
the  usual  forms  of  artificial  nerve  stimuli  may  affect  these 
endings,  and  if  of  sufficient  intensity  can  give  rise  to  pain. 
Until  comparatively  recently  it  has  been  taken  for  granted 
that  the  sensory  phenomena  of  disease  could  be  explained 
only  on  the  assumption  that  the  viscera  were  well  supplied 
with  nerve  fibers  which  could  convey  impulses  leading  to 
the  sensation  of  pain  (Hertz).  Although  as  early  as  1753 
Haller,  as  pointed  out  by  Hertz,  had  failed  to  obtain  any 
evidence  that  the  pleura,  peritoneum,  lungs,  liver,  spleen, 
or  kidneys  of  animals  were  sensitive  to  pain,  the  first  real 
doubt  was  cast  upon  prevailing  belief  when  it  was  observed 
that  during  the  second  stage  of  a  colostomy  the  manipula- 
tion and  cutting  of  the  walls  of  the  colon  in  a  patient  per- 

8 


fectly  conscious  were  unattended  by  pain,  indeed  were 
entirely  without  sensation.  The  subject  then  became  the 
basis  of  wide  interest  and  investigation.  The  publications 
of  different  observers,  notably  Hilton  in  his  classical  lectures 
on  "Rest  and  Pain,"  and  the  investigations  of  Ross,  pub- 
lished in  1858,  stimulated  interest  and  further  work  in  the 
study  of  the  nature  and  methods  of  transmission  of  pain. 

In  his  investigations  of  visceral  diseases  Ross  divided 
pain  into  two  forms,  splanchnic  and  somatic.  His  ideas 
were  very  similar  to  those  which  had  been  previously  ex- 
pressed by  Hilton  and  Lange.  He  thought  that  "  the  impulses 
produced  by  irritation  of  the  peripheral  terminations  of  the 
splanchnic  nerves  were  conducted  by  the  posterior  roots  to 
the  posterior  horns  of  the  spinal  cord,  where  they  diffuse  to 
the  roots  of  the  corresponding  somatic  nerves,  and  thus 
cause  an  associated  pain  in  the  territory  of  distribution  of 
these  nerves."  This  work  of  Ross  opened  up  a  large  field 
for  investigation  and  stimulated  the  splendid  work  of  Head 
and  Mackenzie,  who  still  further  corroborated  the  observa- 
tions of  Hilton  and  Ross,  and  on  the  weight  of  their  authority 
these  ideas  became  generally  accepted.  Head's  work  dealing 
with  the  areas  of  cutaneous  hyperalgesia  occurring  in  visceral 
disease,  by  demonstrating  that  they  are  identical  with  the 
areas  which  receive  their  sensory  nerve  fibers  from  the 
spinal  segments  to  which  the  afferent  fibers  from  the  diseased 
viscera  pass,  proved  conclusively  the  soundness  of  the  earlier 
deductions.  Divergent  views  were  held  by  Mackenzie  and 
Ross  as  a  result  of  their  experiments.  The  former  had 
observed  that  in  visceral  disease  in  addition  to  the  tenderness 
in  the  skin,  as  mapped  out  by  Head,  there  was  a  similar 
sensitiveness  in  the  muscles  and  parietal  subperitoneal  tissue, 
supplied  by  the  corresponding  spinal  segments.  He  as  a 
result  of  his  observations  came  to  the  conclusion  that  all 
pain  in  abdominal  disease  originates  in  the  peripheral 
structures.  Ross,  on  the  other  hand,  adhered  to  the  idea  of 
splanchnic  or  visceral  and  somatic  or  referred  pain.  Since 
this  time  much  additional  work  has  been  done  and  published 
records  of  investigations  by  many  observers  have  accumu- 
lated. From  this  mass  of  work  several  facts  stand  out 
prominently:    (1)   That  any  nerve  ending  may  be  sensitive 


to  some  one  form  of  stimulation  which  has  been  called  "the 
adequate  stimulus,"  but  insensitive  to  all  others.  The 
failure  to  take  this  fact  into  account  explains  a  great  many 
of  the  discrepancies  which  have  occurred  in  the  reports  of 
the  work  of  earlier  observers.  The  adequate  stimuli  for 
pain  vary  for  different  regions  and  structures  of  the  body,  — 
for  instance,  those  for  visceral  pain  are  not  of  the  ordinary 
tactile  or  thermal  types  to  which  the  skin  and  mucous  sur- 
faces so  promptly  respond,  but  are  tension  in  some  form  or 
other.  It  must  not  be  forgotten,  however,  that  while  these 
other  forms  of  stimuli  may  not  be  capable  of  exciting  specific 
receptors  in  the  intestinal  walls,  nevertheless  they  are  capable 
of  inducing  motor  reflex  activities  which  in  turn  cause  con- 
traction, and  those  contractions  which  cause  tension  to 
mount  to  the  deep  sensibility  threshold  result  in  pain.  A 
great  deal  of  discussion  has  been  given  to  the  question  as 
to  the  channels  through  which  intestinal  pain  is  transmitted, 
but  that  pain  is  actually  felt  in  lesions  of  the  intestinal  canal 
cannot  be  doubted.  (2)  That  the  threshold  of  pain,  that 
is,  the  point  at  which  pain  as  a  result  of  any  form  of  stimu- 
lation begins  to  be  felt,  may  be  raised  or  lowered,  according 
to  certain  established  conditions.  (3)  That  tension  in  some 
form  or  other  is  the  commonest,  perhaps  the  sole  cause  of 
visceral  pain.  Meltzer  in  the  course  of  his  investigations 
attempted  to  explain  all  forms  of  colic  as  due  to  a  disturbance 
of  what  he  called  "The  law  of  contrary  innervation,"  which 
is  the  name  he  gave  to  the  well-known  physiological  law  of 
the  intestine,  namely,  that  contraction  in  one  place  is  always 
associated  with  relaxation  just  below.  Interference  with 
this  law  due  to  organic  disease,  or  to  direct  or  reflex  spasm, 
giving  rise  to  tension  as  a  result  of  traction  upon  the  parietal 
attachments,  or  distention  of  the  intestinal  wall,  produces 
visceral  pain  in  some  of  its  protean  manifestations.  Hertz 
and  others  insist  that  this  is  the  sole  cause  of  true  visceral 
pain.  This  pain,  in  turn,  is  referred  to  the  peripheral  struc- 
tures in  accordance  with  the  views  expressed  above. 

From  my  own  clinical  observations  made  in  the  course  of 
surgical  operations  upon  conscious  patients  I  am  convinced 
that  Ross  is  right  in  his  contention  that  there  are  two  forms 
of  pain,  splanchnic  and  somatic,  and  that  in  a  number  of 

10 


conditions  at  least  —  such,  for  instance,  as  the  common 
forms  of  colic,  —  visceral  pain  alone  is  present.  It  is  not 
always  easy,  indeed  not  possible,  to  distinguish  between 
these  two  forms  of  pain,  for  they  are  not  infrequently  both 
present  at  the  same  time. 

As  against  the  idea  that  pain  can  originate  in  the  viscera 
has  been  urged  the  fact  of  the  patient's  inability  accurately 
to  localize  it.  The  same  is  true,  of  course,  of  the  skin,  as  it 
is  well  known  that  cutaneous  irritation  of  certain  parts  of 
the  trunk  cannot  be  localized  within  wide  limits.  The  argu- 
ment is  advanced  that  if  the  pain  of  gastric  ulcer,  for  instance, 
is  produced  in  the  ulcer  itself,  it  should  move  when  the 
stomach  moves,  but,  as  a  matter  of  fact,  the  pain  remains 
stationary.  This  phenomenon  is  explained  by  Hertz  on  the 
ground  of  average  localization,  that  is,  the  pain  is  referred 
to  the  point  on  the  surface  of  the  skin  under  which  the 
stomach  should  normally  lie.  He  would  give  this  as  the 
reason  why  visceral  pain  is  most  accurately  localized  in  those 
viscera  which  move  the  least,  as  the  gall  bladder,  duodenum, 
and  esophagus,  and  is  least  accurately  localized  in  the  more 
mobile  portions,  that  is,  the  large  and  small  intestine. 

Cutaneous  pains  are  as  a  rule  located  more  or  less  accu- 
rately at  the  point  stimulated,  whereas  in  the  case  of  pain 
arising  in  the  internal  organs  this  is  not  the  case.  Here  are 
observed  what  have  been  designated  clinically  as  "referred 
pains."  Head  in  his  classical  studies  of  this  subject  has 
shown  very  conclusively  that  the  different  visceral  organs 
have  a  more  or  less  definite  relation  to  certain  areas  in  the 
skin.  With  painstaking  accuracy  he  has  marked  these  out 
and  determined  their  association  with  the  different  spinal 
segments.  The  misreference  of  pain  observed  is  ascribed 
to  a  diffusion  in  the  nerve  centers.  This  diffusion  Head 
explains  on  the  ground  that  in  the  case  of  a  painful  stimulus 
applied  to  a  part  of  low  sensibility  in  close  central  connec- 
tion with  a  part  of  much  higher  sensibility,  the  pain  pro- 
duced is  felt  in  the  latter  rather  than  in  the  former,  to  which 
the  stimulus  was  actually  applied.  It  is  generally  accepted 
by  physiologists  that  the  afferent  neurones  from  the  viscera 
have  a  common  path  of  entry  into  the  cord  from  the  posterior 
root.    The  theory  of  "referred  pain,"  then,  is  that  "sorae- 

11 


where  in  this  common  path  the  excitement  of  the  splanchnic 
afferents  is  transmitted  to  the  somatic  afferents,  and  that 
the  cerebral  center  for  these  being  stimulated,  the  mind 
suffers  an  illusion  and  refers  the  source  of  the  irritation  out 
to  an  area  of  skin"  (Harris). 

A  knowledge  of  these  few  facts  will  aid  materially  in  the 
understanding  of  that  large  and  interesting  group  of  reflected 
or  referred  pains  with  which  every  surgeon  of  experience 
is  familiar.  It  is  often  difficult  enough  to  determine  with 
any  degree  of  accuracy  the  cause  and  significance  of  a  pain 
in  the  part  directly  affected.  Take,  for  instance,  a  pain 
occurring  in  the  upper  right-hand  quadrant  of  the  abdomen. 
A  great  many  possibilities  at  once  suggest  themselves  to 
any  one  familiar  with  the  pathological  anatomy  of  this 
region.  When,  however,  the  pain  is  referred  to  some  part 
of  the  body  far  distant  from  its  point  of  origin  and  is  accom- 
panied by  no  appreciable  symptoms  suggestive  of  this  fact, 
the  difficulties  in  the  way  of  an  accurate  diagnosis  are 
multiplied  many  fold. 

For  example,  some  years  ago  I  was  called  in  consultation 
to  see  a  youth  of  seventeen  who  the  day  before,  while  return- 
ing from  a  chestnutting  expedition,  and  after  having  eaten 
very  freely  of  the  raw  nuts,  was  suddenly  seized  with  a 
severe  pain  in  the  lower  right  side  of  the  abdomen.  There 
was  no  history  of  similar  previous  attacks.  I  found  the 
boy  in  bed,  his  right  leg  drawn  up.  He  looked  sick,  com- 
plained of  pain  referred  to  the  lower  part  of  the  abdomen. 
Temperature  and  pulse  both  elevated,  nausea  and  vomiting. 
Examination  showed  tenderness  over  the  lower  part  of  the 
abdomen  on  both  sides.  No  muscle  spasm.  Attempts  to 
straighten  the  leg  increased  his  pain.  Hip  joint  negative, 
slight  pain  on  urination.  There  had  been  no  chill.  There 
was  present  a  cough  which  bothered  him  greatly.  Expec- 
toration was  considerable,  whitish.  Examination  of  chest 
was  negative,  except  for  a  few  coarse  rales.  Diagnosis 
uncertain,  probably  appendicitis.  Immediate  removal  to 
the  hospital  was  advised  and  declined  until  the  next  day, 
when  the  patient  entered  the  Johns  Hopkins  Hospital  and 
was  seen  in  consultation  with  several  members  of  the  staff. 
By  this  time  the  sputum  had  become  slightly  blood  tinged. 

12 


His  cough  caused  a  good  deal  of  pain,  especially  in  the  lower 
right  side  of  the  abdomen.  Examination  of  the  chest  showed 
only  evidence  of  slight  bronchitis.  Abdomen  fairly  soft  and 
permitted  deep  palpation  everywhere,  except  low  down  over 
the  symphysis  and  on  the  right  side  just  above  Poupart's 
ligament.  Pressure  here  gave  pain  and  a  slight  muscle 
spasm  was  present.  The  right  thigh  still  remained  flexed 
and  could  not  be  extended  without  pain.  No  tenderness  to 
be  made  out  about  the  hip  joint  or  surrounding  structures. 
Examination  otherwise  negative.  Leucocytes  19,500,  tem- 
perature 104,  pulse  120.  It  was  then  learned  for  the  first 
time  that  the  patient  had  been  exposed  to  typhoid  fever, 
which  fact  influenced  our  opinion  somewhat  toward  a 
possible  typhoid,  although  the  widal  was  negative.  A  central 
pneumonia  with  diaphragmatic  pleurisy  could  not  be  ex- 
cluded. Abdominal  symptoms  referred  to  the  region  of  the 
psoas  muscle  were  also  not  satisfactorily  explained.  Two 
days  later  the  patient  was  seen  by  Dr.  Osier,  who  dictated 
the  following  note:  "Suspicious  spots  in  right  flank  sug- 
gesting rose  spots,  definite  dicrotism  of  pulse,  some  piping 
rales  over  right  base,  some  impairment  in  left  axilla;  there 
is  an  indefinite  mass  just  above  the  symphysis  pubis, 
palpable  and  tender."  Dr.  Osier  concurred  in  the  diagnosis 
of  possible  typhoid  fever.  No  appreciable  change  was 
observed  in  the  patient's  symptoms  during  the  next  two 
days,  when  suddenly  a  swelling  appeared  in  the  upper  part 
of  the  thigh.  Synchronous  with  the  appearance  of  this 
swelling  the  abdominal  pain  and  tenderness  markedly 
improved.  The  diagnosis  was  then  changed  to  acute  epiphy- 
sitis with  osteomyelitis  of  the  upper  end  of  the  femur.  The 
swelling  was  at  once  incised  and  a  considerable  quantity  of 
pus  evacuated.  The  patient  improved  considerably  after 
this  and  was  apparently  on  the  road  to  recovery,  when  he 
developed  a  right-sided  pneumothorax,  to  which  he  quickly 
succumbed. 

The  most  striking  symptom  in  this  case  had  been  from 
the  beginning  intense  pain  in  the  lower  part  of  the  abdomen, 
but  accompanied  by  such  slight  local  tenderness  and  muscle 
spasm  as  to  make  us  doubtful  of  the  existence  of  any  definite 
inflammatory  lesion  in  the  abdomen,  and  for  this  reason 

13 


operation  had  been  declined.  And  yet  it  was  impossible  to 
determine  definitely  as  to  the  nature  of  his  trouble  until  the 
appearance  of  the  swelling  in  the  upper  part  of  the  thigh 
rendered  certain  the  diagnosis. 

One  could  multiply  instances  of  the  confusing  and  mis- 
leading effect  of  referred  pain,  the  pain  in  the  knee  from 
hip  disease,  in  the  ear  from  cancer  of  the  tongue,  in  the 
abdomen  in  Pott's  disease,  in  the  absent  member  after 
amputation,  in  the  shoulder  in  gall  bladder  disease,  and  in 
the  arms  in  angina  pectoris,  but  it  will  suffice  to  direct 
attention  strongly  to  the  fact  that  pain  is  not  infrequently 
referred  to  localities  far  removed  from  the  seat  of  the  causa- 
tive lesion;  and  in  cases  where  local  signs  do  not  correspond 
with  those  usually  observed  in  pain  arising  in  that  locality 
a  thorough  search  should  be  instituted  for  a  possible  ex- 
planation existing  elsewhere.  In  doing  so  it  is  well  to  bear 
in  mind  Hilton's  axiom,  namely,  that  "Pain  felt  in  any 
part  must  be  expressed  by  the  nerves  supplying  the  part." 

There  is  a  definite  psychology  of  pain  difficult  to  under- 
stand, perhaps,  but  nevertheless  well  recognized  by  every 
intelligent  observer.  Some  one  has  said  that  pain  is  the 
resultant  of  two  factors,  the  lesion  and  the  patient,  and  in 
order  to  arrive  at  an  intelligent  appreciation  of  its  true 
significance  both  must  be  thoroughly  understood. 

The  mental  state  of  the  sufferer  varies  greatly  in  different 
individuals  and  at  different  times.  Frequently  he  will 
unintentionally  deceive  the  physician  by  his  inability 
accurately  to  describe  his  sensations;  especially  is  this  true 
of  pain,  which  is  purely  subjective.  Again  he  may  do  so 
intentionally  by  false  statements  as  to  its  character,  location, 
and  intensity.  In  some,  pain  brings  out  the  heroic,  often  to 
a  very  unexpected  degree.  In  others  it  develops  the  hitherto 
unsuspected  "yellow  streak."  It  does  not  always  follow  that 
because  a  patient  bears  what  appears  to  be  a  great  amount 
of  pain  with  remarkable  fortitude,  that  that  individual  is 
more  deserving  of  credit  or  shows  greater  self-control  than 
the  one  who  does  not;  for  it  is  a  well-established  fact  that 
pain  is  not  felt  to  the  same  degree  by  all  individuals  alike, 
some  are  much  more  tolerant  of  it  than  others.  Indeed  cases 
have  been  reported  of  individuals  naturally  analgesic  who 

14 


do  not  seem  to  suffer  pain  at  all.  The  analgesia  of  hysteria 
is  also  well  known  and  usually  easily  recognized. 

What  may  cause  intense  suffering  in  one  will  produce 
little  effect  upon  another.  I  was  struck  with  this  fact  not 
long  since  while  reducing  a  Pott's  fracture  in  the  case 
of  a  young  man  who  was  in  other  respects  in  excellent  health. 
I  suggested  giving  him  an  anesthetic,  but  he  requested  that 
I  proceed  with  my  manipulations  without  it.  I  did  so,  and 
with  considerable  difficulty  and  the  exercise  of  some  neces- 
sary force  succeeded  in  satisfactorily  reducing  the  fracture. 
During  the  whole  procedure  he  had  sat  up  in  bed  and  watched 
what  was  being  done  with  great  interest  and  with  little 
evidence  of  suffering.  After  it  was  over  he  declared  that, 
while  it  had  not  been  an  altogether  agreeable  sensation,  he 
had  suffered  no  pain  of  any  consequence.  On  the  other  hand, 
it  is  a  not  infrequent  occurrence  to  hear  a  patient  declare, 
and  with  every  evidence  of  truthfulness,  that  he  or  she  was 
suffering  extreme  agony,  when  there  was  no  demonstrable 
physical  or  pathological  basis  to  lead  one  to  believe  that 
such  was  the  case.  What  is  known  as  temperament  plays 
a  great  part  in  the  ability  of  an  individual  to  bear  pain. 
Just  what  this  is  it  would  be  difficult  to  state  in  words.  The 
old  idea  of  the  knowledge  of  the  constitution  of  the  patient 
supposed  to  be  possessed  by  the  family  doctor  has  something 
to  commend  it. 

Being  but  a  subjective  symptom  it  is  at  times  hard  to 
estimate  the  degree  of  pain,  or  indeed  whether  or  not  it  is 
present  at  all,  as  it  is  easy  to  feign.  There  are  certain  signs, 
however,  which  denote  intense  suffering  and  which  when 
present  are  usually  unmistakable,  the  pinched  features,  the 
knotted  brow,  the  rolling  eyes  with  widely  dilated  pupils, 
the  ashen  countenance,  the  cool  and  clammy  skin,  the 
thready  pulse,  the  increased  blood  pressure,  the  hands 
alternately  clenched  and  opened,  grasping  wildly  at  sur- 
rounding objects  or  persons,  or  perhaps  pressed  firmly  over 
the  painful  area,  add  to  this  the  cries  and  groans,  the  bodily 
contortions  and  writhing  so  frequently  seen  in  this  con- 
nection, and  a  picture  is  presented  so  definite  and  unmis- 
takable that  it  cannot  fail  to  be  recognized.  But  it  is  not 
always  thus,  —  one  sees  now  and  then  exhibitions  of  won- 

15 


derful  fortitude  in  the  bearing  of  suffering,  when  not  a  groan 
escapes  the  sufferer  nor  any  evidence  of  the  existence  of 
pain,  save  that  indefinable  expression  of  countenance  so  well 
understood  by  the  initiated.  Is  there  or  can  there  be  any- 
thing more  sublime  or  more  inspiring  in  its  effect  upon  others 
than  such  an  exhibition  of  self-control?  Pain  may  be  so 
intense  as  to  notably  depress  the  heart's  action,  even  to 
temporary  arrest.  If  of  great  intensity  it  may  be  complete 
and  death  may  follow. 

The  fear  of  pain  plays  a  large  part  in  its  psychology.  So 
terror  stricken,  indeed,  may  an  individual  at  times  become 
as  to  seek  self-destruction  in  order  to  avoid  a  repetition  of 
some  dreadful  experience.  It  also  exercises  a  markedly 
deterring  effect  in  various  ways  upon  conduct,  thus  pre- 
venting, through  fear  of  painful  consequences,  many  foolish 
actions. 

The  wearing  effect  of  pain  upon  one's  powers  of  inhibition 
must  have  attracted  the  attention  of  every  surgeon.  So 
often  does  one  see  the  defenses,  one  after  another,  broken 
down  by  continued  and  recurring  pain,  —  the  individual 
whose  fortitude  in  the  beginning  may  have  been  surprising 
may  gradually,  owing  to  this  peculiar  effect,  become  in  the 
course  of  time  the  whining,  complaining  creature,  shrinking  and 
crying  aloud  at  the  slightest  touch,  a  sore  trial  and  an  object 
of  pity  alike  to  every  one  with  whom  he  comes  in  contact. 

Others  may  become  embittered  and  hardened,  their 
dispositions  soured,  their  whole  mental  attitude  and  their 
outlook  upon  life  in  general  changed  and  rendered  thoroughly 
pessimistic  by  suffering. 

There  is  upon  the  other  hand  perhaps  no  burden  which 
humanity  is  called  upon  to  bear,  unless  it  may  be  grief,  which 
itself  is  looked  upon  as  a  form  of  mental  pain,  that  may 
have  so  refining  and  ennobling  an  influence,  or  may  bring 
out  more  forcibly  the  higher  qualities  of  head  and  heart,  or 
develop  nobler  traits  of  character.  How  forcibly  is  this 
fact  now  and  then  brought  home  to  all  of  us  as  we  have 
looked  into  the  face  of  some  patient  sufferer,  purified  and 
rendered  truly  beautiful  by  the  discipline  of  pain,  and  how 
much  it  has  increased  our  admiration  and  respect  for  human 
kind. 

16 


Owing  to  the  inability  of  the  sensory  apparatus  to  transmit 
two  strong  impressions  at  the  same  time,  the  stronger  of  the 
two  for  the  moment  will  monopolize  the  attention  of  the 
individual.  The  newspapers  nowadays  are  rilled  with  thrill- 
ing accounts  of  valorous  deeds  performed  upon  the  battle- 
fields by  brave  soldiers  who,  themselves  severely  wounded, 
in  the  enthusiasm  of  the  moment  and  unmindful,  indeed  for 
the  time  being  unconscious  of  their  own  suffering,  have 
rescued  some  more  seriously  wounded  comrade,  and  then 
after  this  has  been  accomplished,  for  the  first  time  conscious 
of  their  own  pain,  have  collapsed. 

Not  long  since  I  was  interested  and  not  a  little  amused  to 
observe  in  the  crowd  of  yelling,  dancing  students  who 
swarmed  upon  the  field  at  the  end  of  a  closely  contested 
game  of  football,  a  patient  of  mine,  a  student  in  the  victorious 
college,  who  not  long  before  had  severely  injured  his  knee 
while  playing  in  a  practice  game,  and  since  which  time  on 
account  of  severe  pain  had  been  able  to  go  about  only  with 
the  aid  of  crutches.  He  was  careering  as  madly  as  the 
nimblest  among  them,  one  crutch  had  been  discarded,  the 
other  was  waving  frantically  in  the  air  over  his  head,  —  for 
the  moment,  at  least,  in  the  exuberance  of  joy  in  the  success 
of  his  team  he  appeared  utterly  oblivious  to  pain.  The  next 
day  when  I  saw  him  it  is  needless  to  say  he  was  paying  the 
penalty. 

Certain  sensations  which  are  not  ordinarily  associated 
with  pain  may,  when  of  sufficient  intensity  or  when  long 
enough  continued,  gradually  merge  into  it,  —  for  instance, 
those  of  fullness  and  emptiness  accompanying  an  over- 
distended  or  an  empty  stomach.  To  one  who  has  survived 
the  starvation  treatment  of  typhoid  fever  as  practised  in  this 
hospital  twenty-five  years  ago,  the  pangs  of  hunger  are  no 
figment  of  the  imagination,  but  a  real  pain  that  leaves  a 
lasting  impression  upon  the  mind  of  the  sufferer.  I  speak 
feelingly.  So  also  with  heat  and  cold,  and  with  certain 
forms  of  local  stimulation,  chemical  and  otherwise,  of  the 
tissues  of  the  body,  at  first  perhaps  grateful,  even  pleasurable, 
later  and  almost  unconsciously,  as  the  intensity  increases, 
becoming  painful.  So  too  every  one  who  has  experienced  a 
severe  pain  or  has  had  the  opportunity  to  observe  its  effecXs 

17 


upon  others  must  have  noticed  with  satisfaction  after  its 
subsidence  the  sensation  of  well-being,  amounting  at  times 
and  especially  in  individuals  of  certain  temperaments  almost 
to  exhilaration.  This  is  peculiarly  so  in  women  after  the 
completion  of  a  hard  and  painful  labor.  One  can  readily 
appreciate  and  understand  the  philosophy  of  the  little 
darkey  when  he  said  he  "sho'  did  like  to  git  kicked  on  de 
shins,  cause  dey  felt  so  good  after  dey  stopped  hurtin'." 

"Every  pain  has  its  distinct  and  pregnant  signification  if 
we  will  but  carefully  search  for  it."  This  sentence,  quoted 
from  that  classical  work  by  Hilton,  entitled  "Lectures  on 
Rest  and  Pain,"  expresses  better  than  can  I  in  any  other 
words  the  idea  that  I  had  in  mind  in  choosing  the  subject  for 
this  address.  If  this  be  true  then  it  follows  of  necessity  that 
the  surgeon  when  consulted  by  a  patient  for  the  relief  of  his 
pain  will  not  have  performed  his  whole  duty  toward  his 
patient  if  he  has  not  made  use  of  every  means  in  his  power 
to  discover  just  what  is  the  peculiar  significance  of  this 
particular  pain.  It  does  not  necessarily  follow  that  even  by 
careful  searching  this  significance  can  always  be  found  out, 
but  this  fact  does  not  relieve  the  surgeon  of  the  obligation 
to  make  a  bona  fide  effort  to  discover  it.  This  search  in  turn 
may  involve  some  very  complex  and  far-reaching  problems. 
It  presupposes  upon  the  part  of  the  surgeon  the  requisite 
amount  of  knowledge  and  training,  coupled  with  the  ability, 
the  willingness,  and  the  facilities  necessary  to  carry  out  the 
examination  and  investigation  in  order  to  obtain  the  neces- 
sary data;  then  more  important  than  all  is  the  judgment 
with  which  properly  to  interpret  the  findings.  For  in 
diagnosis  symptoms  are  of  value  only  when  we  are  able  to 
interpret  them  in  terms  of  the  particular  disease  under  con- 
sideration. This  is  especially  true  in  the  case  of  subjective 
symptoms,  where  so  much5  reliance  has  to  be  placed  upon  the 
word  of  the  patient. 

A  study  of  pain  by  itself  is  of  interest  and  value  to  the 
physician  from  a  diagnostic  standpoint.  But  when  taken  in 
connection  with  other  symptoms  its  proper  interpretation  is 
rendered  far  easier.  In  attempting,  then,  to  determine  the 
significance  of  a  certain  pain  it  is  advisable  not  to  dissociate 
it  from  its  attendant  clinical  phenomena;  thus  a  pain  in  the 

18 


epigastric  region  of  a  youth,  when  accompanied  by  tender- 
ness and  rigidity  of  the  right  rectus  muscle  in  its  lower  half,  a 
rise  in  pulse  rate  and  temperature,  and  an  increase  in  the 
leucocyte  count,  would  very  strongly  suggest  an  acute 
appendicitis  rather  than  any  other  acute  abdominal  affec- 
tion. This  statement  would  seem  elemental  and  almost  self- 
evident.  But  the  frequency  with  which  one  sees  the  mistake 
made  of  failing  to  recognize  this  fact  prompts  the  reference 
to  it.  Says  Maurice  Richardson,  "Alone,  pain  indicates 
danger  in  general;  in  combination  with  other  signs  it  indi- 
cates danger  in  particular  and  guides  the  surgeon's  hand  to 
its  source."  But  it  alone  cannot  always  be  relied  upon  in 
estimating  the  nature  and  extent  of  the  causative  lesion. 
Many  authors  have  dealt  with  this  particular  aspect  of  our 
subject.  Mackenzie  especially  has  drawn  attention  to  the 
valuable  aid  to  diagnosis  afforded  by  a  careful  study  of  pain 
and  the  nervous  phenomena  which  accompany  it.  In  our 
effort  to  elicit  the  more  obscure  symptoms  that  arise  from 
disordered  functions  of  diseased  viscera  it  has  sometimes 
happened  that  insufficient  attention  has  been  paid  to  the 
commoner  and  more  obvious  symptoms.  The  laboratory 
methods  of  clinical  diagnosis,  the  so-called  special  tests,  are 
of  the  utmost  importance,  and  any  attempt  to  decry  them 
should  be  deprecated.  Yet  it  cannot  be  denied  that  to  the 
general  practitioner  at  least,  who  is  the  one  who  sees  the 
patient  first  and  who  largely  determines  the  course  of  treat- 
ment to  be  thereafter  followed,  the  practical  value  of  these 
methods  is  small  as  compared  to  the  information  to  be  gained 
by  the  recognition  and  proper  understanding  of  the  symptoms 
arising  from  reflex  stimulation  of  the  nervous  system.  We 
must  not  shut  our  eyes  to  the  fact  that  it  is  only  in  a  small 
proportion  of  cases  which  the  general  practitioner  sees  that 
the  more  intricate  methods  of  examination  are  of  use  or  are 
available.  In  the  great  majority  of  cases  the  reflex  symptoms 
lie  ready  to  hand,  if  only  they  are  recognized,  and  it  is  on 
these  alone  that  he  has  often  to  rely  for  early  diagnosis  and 
treatment.  How  important  it  is,  then,  that  the  commoner 
symptoms,  such  as  pain,  should  be  carefully  studied,  so  that 
their  message  may  be  correctly  interpreted,  for  it  is  upon  the 
recognition  of  the  early  stages  of  disease  that  so  much 

19 


depends.  This  fact  needs  to  be  especially  emphasized  at 
the  present  time,  when,  owing  to  the  ease  and  comparative 
safety  with  which  an  abdominal  exploration  can  be  per- 
formed, the  tendency  in  some  quarters  is  setting  so  strongly 
toward  recourse  to  this  easier  and  shorter  method  rather 
than  to  a  careful  and  painstaking  examination  and  analysis 
of  the  symptoms  presented.  As  a  result  many  operators  (I 
use  the  word  advisedly,  all  operators  are  not  surgeons)  have 
no  clear  idea  in  their  minds  with  regard  to  the  nature  and 
origin  of  many  easily  recognized  evidences  of  disease.  Espe- 
cially is  this  true  of  the  so-called  reflex  phenomena  of  visceral 
disease.  Of  these  pain  is,  of  course,  the  most  constant  and 
most  important  factor.  It  is  easy  to  satisfy  the  patient 
by  calling  his  pain  a  neuritis  or  a  neuralgia.  But  before 
doing  so  the  conscientious  physician  will  consider  most  care- 
fully the  possibility  of  the  existence  of  some  other  cause, 
perhaps  of  visceral  disease,  and  will  take  immediate  steps  to 
eliminate  it  as  a  possibility  or  to  establish  its  presence  as  a 
certainty.  It  is  of  the  utmost  importance  that  the  true 
significance  of  these  common  symptoms,  of  which  pain  is 
the  most  constant,  should  be  recognized. 

Do  not  discard  the  old  and  well-recognized  symptoms  and 
methods  for  the  new  exclusively,  but  a  study  of  the  common 
and  easily  ascertained  facts  by  newer  methods  will  throw  a 
new  light  upon  them  and  allow  of  advances  that  can  be  made 
in  no  other  way.  At  the  same  time  it  should  not  be  forgotten 
that  clinical  contributions  to  our  knowledge  in  this  direction 
constitute  research  work  just  as  truly  when  made  in  the 
wards,  by  the  bedside  of  the  patient,  as  when  performed 
upon  animals  in  the  laboratory. 

Pain  as  a  diagnostic  factor  is  of  the  utmost  importance. 
It  has  been  estimated  that  ninety  per  cent  of  all  diseases  either 
begin  with  it  or  are  at  some  time  or  other  in  their  course 
accompanied  by  it.  In  some  cases  it  forms  the  all-important 
factor,  in  others  it  is  only  an  incident.  The  character  of  the 
pain  may  be  of  great  assistance  in  determining  its  significance. 
Certain  terms  are  used  by  patients  so  constantly  in  describing 
pain  arising  from  certain  structures  or  pathological  con- 
ditions that  they  have  come  to  have  a  definite  diagnostic 
value.    For  instance,  pain  arising  in  inflammatory  processes, 

20 


particularly  of  bone,  is  described  as  "  boring"  or  "  throbbing" 
or  "jumping"  in  character.  Nerve  pains  are  consistently 
described  as  burning,  shooting,  or  stabbing,  while  I  have  been 
struck  with  the  frequency  with  which  the  terms  "stinging" 
or  "sticking"  have  been  used  by  patients  to  describe  the 
painful  sensations  experienced  fairly  early  in  cancer  of  the 
breast.  While  these  and  other  descriptive  terms  cannot  be 
said  to  be  of  any  absolute  value  they  certainly  are  suggestive. 

The  relation  that  pain  may  bear  to  certain  events  is  of 
great  assistance  at  times  in  differentiating  between  various 
conditions.  Can  anything  be  more  characteristic  than  the 
pain  of  gastric  or  duodenal  ulcer  coming  on,  as  it  frequently 
does,  at  a  definite  interval  after  the  ingestion  of  food?  Or, 
more  striking  still,  the  pain  of  an  anal  fissure  beginning 
shortly  after  defecation,  increasing  for  several  hours  until 
the  acme  of  intensity  is  reached,  then  gradually  decreasing 
until  it  entirely  disappears  and  leaves  the  patient  in  perfect 
comfort  until  this  experience  is  repeated  after  the  next  stool? 

Pain  seems  to  be  affected  by  the  time  of  day.  It  is  notori- 
ously worse  at  night.  How  often,  for  instance,  does  one  meet 
with  a  patient  suffering  from  an  inflammatory  bone  lesion 
who  gives  the  history  of  inability  to  sleep  at  night  because 
of  the  pain,  boring  in  character,  which  begins  in  the  latter 
part  of  the  afternoon  and  gradually  increases  in  intensity 
through  the  night  until  towards  daylight,  when  it  rather 
suddenly  decreases  to  such  an  extent  that  sleep  becomes 
possible. 

Weather  conditions  undoubtedly  have  their  effect  upon 
pain.  Especially  is  this  true  in  the  changes  from  good  to 
bad,  which  not  infrequently  increase  the  pain  to  such  an 
extent  as  to  enable  the  patient  to  predict  their  occurrence 
with  remarkable  accuracy.  This  has  been  attributed  to 
changes  in  atmospheric  pressure,  which  affect  the  nerve 
mechanism  in  much  the  same  way  as  changes  in  the  blood 
pressure.  This  is  probably  the  reason  why  pain  is  more 
noticeable  at  night,  although  the  quiet  and  the  absence  of 
other  things  to  distract  one's  attention  undoubtedly  have 
their  effect.  It  may  be  that  the  senses  are  more  acute  and 
so  perceive  slighter  irritation  than  by  day.  The  recumbent 
posture,  and  in  the  case  of  certain  organs,  e.  g.,  bladder  or 

21 


stomach,  their  being  more  full  or  more  empty  than  by  day 
may  make  a  difference. 

Racial  characteristics  are  of  importance.  Those  of  the 
so-called  phlegmatic  type  bear  pain  better  than  others. 

Sex  is  a  factor  not  to  be  disregarded.  One  observer  as 
the  result  of  his  investigations  insists  that  the  well-known 
ability  of  women  to  endure  pain  is  due  to  the  fact  that  their 
sensibility  to  painful  stimuli  of  all  sorts  is  appreciably  less 
than  that  of  men. 

An  important  fact  to  be  borne  in  mind  is  that  abdominal 
pain  is  usually  accompanied  by  spasm  of  the  muscles  over- 
ling the  painful  area,  —  the  viscero-muscular  reflex  of 
Mackenzie.  Especially  is  this  true  of  the  recti,  which  have 
the  power  of  segmental  contraction  over  the  area  of  in- 
flammation, and  thus  may  strongly  simulate  tumors  and 
swellings  of  various  sorts. 

A  striking  instance  of  the  protective  action  of  pain  is 
seen  in  the  case  of  the  various  inflammations  of  the  serous 
surfaces.  Here,  as  Crile  points  out,  the  infections  which 
are  associated  with  pain  are  those  in  which  the  trouble  may 
be  made  more  widespread  by  muscular  activity,  hence  the 
tendency  toward  localization  of  the  inflammatory  process 
which  is  encouraged  by  the  fixation  of  the  parts  due  to  the 
muscular  rigidity  which  always  accompanies  to  a  greater 
or  less  degree  inflammations  of  serous  surfaces. 

The  absence  of  pain  where  it  may  be  reasonably  expected 
to  be  present  or  its  sudden  cessation  in  the  course  of  certain 
diseases  are  frequently  of  the  greatest  diagnostic  significance. 
Take,  for  instance,  a  tumor  of  the  breast  that  has  been 
discovered  accidentally,  without  previous  warning  of  its 
presence  in  the  nature  of  uncomfortable  sensations,  is  much 
more  apt  to  be  of  a  serious  nature  than  one  which  has  given 
rise  to  pain  and  discomfort.  I  am  conscious  always  of  a 
sense  of  relief  when  a  woman  who  has  presented  herself  with 
a  tumor  of  the  breast  tells  me  that  she  has  suffered  great 
pain  in  it,  as  this  usually  means  that  it  is  benign. 

On  the  other  hand,  the  history  of  the  sudden  cessation  of 
pain  in  the  course  of  an  acute  inflammation  in  the  right  side 
of  the  abdomen,  for  instance,  may  be  of  the  gravest  import, 
particular^  if  not  associated  with  a  corresponding  drop  in 

22 


the  temperature,  pulse  rate,  and  leucocyte  count.  Under 
these  circumstances  it  is  an  unfailing  index  of  gangrene  or 
rupture  of  the  appendix,  or  of  the  sudden  breaking  down  of 
the  protective  barriers  between  an  abscess  and  the  general 
peritoneal  cavity,  a  catastrophy  which,  unfortunately,  is 
not  infrequently  misunderstood  and  unrecognized  by  the 
uninitiated. 

As  pointed  out  by  Mayo  in  one  of  the  previous  Ether  Day 
addresses,  medicine  owes  a  great  debt  to  surgery.  Recent 
accumulated  observations  upon  the  operating  table  have 
laid  the  foundation  of  a  true  pathology  of  the  living,  and 
have  enabled  us  to  recognize  that  there  is  a  definite  anatomi- 
cal cause  for  many  well-recognized  groups  of  symptoms  which 
had  hitherto  been  regarded  as  functional  in  origin.  Through 
the  medium  of  surgical  operations  now  performed  with  great 
frequency  and  safety,  but  which  were  formerly  regarded  as 
quite  out  of  the  question,  we  have  been  taught  the  true 
significance  of  many  of  the  symptoms  which  hitherto  have 
been  universally  misunderstood.  Especially  is  this  true  with 
regard  to  the  affections  that  have  to  do  with  the  abdominal 
viscera,  for  here  abdominal  operations  have  added  enor- 
mously to  our  knowledge  of  the  significance  of  pain  by 
demonstrating  both  its  immediate  and  its  contributing 
causes. 

But  although  the  significance  of  certain  painful  sensations 
may  be  thus  understood,  their  actual  cause  is  in  many 
instances  as  obscure  as  ever.  The  difficulty  lies  in  trying  to 
understand  the  origin  of  pathological  sensations  so  long  as 
the  degree  of  sensibility  of  healthy  or  diseased  organs  to 
various  stimuli  remains  largely  unknown. 

Pain  is  probably  the  most  generally  present  as  well  as 
the  most  trying  of  all  symptoms,  and  therefore  the  most 
important  as  an  aid  to  diagnosis  and  as  a  monitor  in  directing 
and  fixing  the  attention  of  the  patient  to  the  fact  that  there 
is  something  wrong.  To  this  extent  it  is  distinctly  beneficial. 
So  it  is,  then,  that  pain  is  not  always  wholly  harmful  in  its 
effects  upon  the  individual  or  the  race,  and,  as  such,  is  a 
not  unmixed  evil,  at  times  even  a  real  blessing  in  disguise. 

The  especial  value  of  pain  to  the  patient  lies  in  the  fact 
that  in  most  pathological  conditions,  if  it  is  not  the  first  index 

23 


of  existing  trouble,  it  is  nevertheless  the  first  whose  warnings 
are  heeded. 

Incidentally  pain  is  a  good  friend  to  the  doctor  as  well. 
It,  more  than  any  other  factor,  brings  him  patients.  For 
while  other  and  sometimes  even  more  significant  symptoms 
may  have  existed  unheeded  for  a  long  time,  it  is  only  a 
matter  of  a  bad  enough  pain  when  every  one  is  driven  to  seek 
relief  at  the  hands  of  his  doctor.  Failing  in  this  he  now 
willingly,  yes,  eagerly,  seeks  the  formerly  dreaded  surgeon. 
Indirectly  pain  may  serve  the  patient  a  good  turn  through 
the  medium  of  his  doctor,  for  it  is  unquestionably  true  that 
the  surgeon  who  has  himself  been  operated  upon  as  a  result 
thereof  is  apt  to  display  a  more  intelligent  and  sympathetic 
interest  in  his  patient's  comfort.  In  his  hands  unnecessarily 
rough  manipulation  of  sensitive  structures  and  too  tight 
bandages  are  apt  to  be  of  infrequent  occurrence. 

In  these  latter  days  when,  owing  to  the  predominating 
influence  of  certain  individuals  or  schools  of  medicine,  the 
trend  of  medical  teaching  has  set  so  strongly  toward  thera- 
peutic nihilism,  one  is  apt  to  forget  that  the  duty  of  the 
physician  or  surgeon  does  not  end  with  the  completion  of 
an  exhaustive  and  scientifically  accurate  physical  examina- 
tion and  diagnosis,  but  that  it  is  just  as  much  a  part  of  it 
to  treat  the  ills,  physical  and  mental,  real  or  imaginary,  of 
his  patient.  Indeed  it  not  infrequently  happens  that  the 
treatment  of  the  case  may  require  a  far  greater  exercise  of 
knowledge  and  of  judgment  than  the  diagnosis,  which  in 
many  cases  can  be  made  in  the  laboratory  without  even 
seeing  the  patient.  It  is  not  my  purpose  to  belittle  in  any 
way  the  value  to  the  physician  of  diagnostic  ability  of  the 
highest  order,  —  far  from  it,  —  but  I  do  wish  to  emphasize 
the  necessity  of  paying  greater  attention  to  the  complaints  of 
the  patient,  especially  to  his  history  of  pain,  failure  to  relieve 
which,  upon  the  part  of  the  doctor,  is  so  apt  to  be  followed 
by  a  resort  to  the  charlatan  and  the  quack.  Recognition 
of  this  fact,  aided  greatly  by  the  untiring  efforts  of  a  member 
of  the  medical  staff  of  this  hospital,  Richard  Cabot,  is  slowly 
gaining  headway.  The  profession  —  largely  due,  I  am 
constrained  to  believe,  to  a  misconception  of  its  duty  in  this 
regard,  to  faulty  teaching,  and  as  a  reaction  against  over- 

24 


dosage  and  the  blind  administration  of  drugs  —  has  neglected 
its  duty  in  this  respect.  I  shall  never  forget  an  incident  that 
happened  early  in  my  professional  career  and  which  made  a 
lasting  impression  upon  me.  An  elderly  physician,  a  type 
of  the  old  school  family  physician,  was  ill  with  angina 
pectoris,  from  which  he  suffered  paroxysms  of  intense  pain. 
He  was  attended  by  the  foremost  physician  of  the  city,  a 
leader  in  his  profession,  a  professor  of  medicine  in  the  local 
school.  Realizing  the  desperate  and  hopeless  character  of 
his  malady,  little  had  been  done  for  the  patient  save  careful 
nursing  and  rest  in  bed.  I  happened  to  be  present  upon  the 
occasion  of  one  of  the  attending  physician's  characteristic 
visits,  a  cheer}'  greeting,  a  jolly,  a  glance  at  the  chart,  a 
momentary  examination  of  the  chest,  a  whispered  conversa- 
tion with  the  nurse,  a  skillful  interruption  of  attempted 
statements  or  parrying  of  questions  upon  the  part  of  the 
patient,  a  short  adieu,  and  a  rather  hurried  exit,  which  in 
this  instance  was  delayed  somewhat  by  a  vehement  outburst 
upon  the  part  of  the  patient  of  righteous  indignation  that 
no  apparent  steps  had  been  taken  toward  the  relief  of  the 
intense  pain  from  which  he  was  suffering.  Turning  to  me 
the  patient  exclaimed:  " What's  the  use  of  having  the  best 
doctor  in  the  city  if  he  does  nothing  but  make  a  diagnosis 
and  give  you  a  jolly?  I  am  suffering  agonizing  pain  and  I 
want  some  relief.  I  had  rather  have  a  fifth-rate  doctor  who 
relieved  my  pain  than  the  best  doctor  in  the  country  who 
does  nothing  but  make  a  diagnosis."  It  is  only  fair  to  add 
that  this  plea  brought  the  desired  relief  in  the  shape  of  a 
p.r.n.  order  for  a  hypodermic  of  morphia. 

It  must  not  be  forgotten  that  the  good  effects  of  pain  occur 
early  in  the  course  of  the  disease.  Later,  and  the  longer  it  is 
continued,  the  more  injurious  it  becomes.  This  fact,  should 
materially  modify  its  treatment.  In  the  beginning  and  until 
the  diagnosis  has  been  made,  or  at  least  until  the  possible 
causes  of  the  pain  have  been  as  far  as  possible  determined, 
the  effect  of  the  pain,  by  calling  attention  to  the  existence  of 
trouble  and  helping  to  locate  it,  is  distinctly  beneficial. 
During  this  period  anodynes  and  analgesics,  except  in 
extreme  cases,  should  be  withheld.  But  as  soon  as  the  pain 
has  ceased  longer  to  be  of  service,  and  by  its  continuance 

25 


can  only  do  harm  by  reducing  the  patient's  resistance  and 
exhausting  his  nervous  energy,  then  it  is  that  relief,  adequate 
and  complete,  is  urgently  indicated.  But  just  here  is  required 
the  exercise  of  that  sine  qua  non  for  the  proper  carrying  out 
of  all  surgical  procedures,  namely,  good  judgment.  It  is 
essential  to  the  successful  treatment  of  any  case  where  pain 
is  a  prominent  feature  to  know  when  to  withhold  anodynes  so 
as  not  to  mask  the  clinical  picture,  and  when  to  administer 
them.  For  upon  the  full  recognition  of  this  fact  will  not 
infrequently  rest  success  or  failure.  Just  here  a  word  of 
warning  and  protest  ought  to  be  sounded  against  the  practice 
which  is  far  too  prevalent,  namely,  the  indiscriminate  use 
of  drugs  of  all  sorts,  either  with  or  without  the  recommenda- 
tion of  a  physician.  My  attention  was  directed  to  this  only 
recently,  when  I  was  called  to  see  a  girl  of  thirteen  who  had 
been  suffering  greatly  from  recurrent  attacks  of  headache, 
and  for  which  her  mother  told  me  she  had  upon  her  own 
authority  been  giving  the  child  for  some  time  doses  of 
gr.  xx  of  aspirin  three  times  daily,  the  ill  effects  of  which 
were  very  apparent  in  her  condition.  Far  too  great  risks 
are  thus  incurred  of  establishing  the  drug  habit  in  susceptible 
individuals. 

The  desired  results  may  usually  be  obtained  by  the 
competent  and  conscientious  surgeon,  while  at  the  same 
time  safeguarding  the  best  interests  of  the  patient. 

The  proper  use  of  drugs  directed  toward  the  relief  of  pain 
may  be  productive  of  great  good  in  materially  lessening  its 
ill  effects,  by  robbing  disease  of  its  greatest  terror,  by  render- 
ing far  less  formidable  surgical  operations,  and  shortening 
convalescence  through  the  conservation  of  physical  and 
nervous  energy.  There  are  many  agencies  at  our  disposal 
in  addition  to  drugs  to  be  used  for  this  purpose.  Hilton 
early  called  attention  to  the  great  therapeutic  value  of 
physiological  rest.  The  X-rays  and  radium  are  useful  in 
relieving  the  pain  of  inoperable  carcinoma.  Crile  with  his 
anoci-association  has  made  a  distinct  addition  to  our 
armamentarium.  But  among  them  all,  and  their  name  is 
legion,  ether  is  easily  the  first,  and,  all  things  considered,  has 
for  general  use  no  real  rival. 

Fortunately  the  beneficent  effect  of  ether  is  most  felt  in 

26 


that  large  group  of  cases  in  which  pain  accomplishes  no 
good  purpose.  The  pain  of  a  surgical  operation  can  be  of 
no  possible  advantage  either  to  the  patient  or  the  surgeon. 
On  the  contrary,  it  greatly  exhausts  the  nervous  energy  of 
the  patient,  lowers  his  resisting  powers,  and  so  delays  con- 
valescence, while  it  interferes  very  materially  with  the 
operations  of  the  surgeon,  not  only  physical,  but  mental. 
For  no  human  being  —  and  I  have  found  surgeons  as  a  class 
intensely  human  as  well  as  humane  —  can  do  his  best 
knowing  that  he  is  inflicting  untold  suffering  upon  his 
patient;  and  no  patient,  under  the  stimulus  of  such  intense 
physical  pain,  can  remain  sufficiently  quiet  to  permit  the 
surgeon  to  do  his  work  under  satisfactory  conditions. 

While  in  its  immediate  or  its  after  effects  it  may  not  be 
an  ideal  anesthetic,  nevertheless  when  properly  administered, 
as  it  should  always  be  by  expert  hands,  either  alone  or  when 
preceded  by  or  in  combination  with  other  drugs,  as  practised 
in  certain  clinics,  the  good  effects  of  ether  are  so  pronounced 
and  its  ill  effects  so  reduced  to  the  minimum,  while  at  the 
same  time  the  risks  are  so  infinitesimal  as  to  make  it  alto- 
gether the  greatest  boon  ever  given  to  suffering  humanity. 
No  wonder,  then,  that  the  trustees  of  the  Massachusetts 
General  Hospital  should  have  instituted  the  custom  of 
meeting  annually  to  commemorate  the  first  public  use  of 
ether  in  the  performance  of  a  surgical  operation  in  this 
hospital  sixty-eight  years  ago.  All  honor  to  the  great  names 
of  Morton  and  Warren,  and  to  this  noble  institution,  for  their 
respective  parts  in  that  epoch-making  event. 


27 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  rules  of  the  Library  or  by  special  arrange- 
ment with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

!■  ?*%  "b"  s\ 

C28(i14i)m100 

COLUMBIA  UNIVERSITY  LIBRARIES 


0064223353 


